Adult Circumcision Registration

Patient Information
Name**
First Last
Date of Birth**
MM slash DD slash YYYY
Healthcare Card Number
Address**
Street Address Address Line 2 City Province Postal Code
Preferred Phone**
Email**
Emergency Contact Name**
First Last
Emergency Contact Phone**
How did you hear about us?**
- Online / Google
- GP / Doctor's Referral
- Friend / Family Member
- Radio
Medical History
Do you have a history of easy bruising?**
- Yes
- No
Do you have nosebleeds with little or no trauma?**
- Yes
- No
Have you ever had abnormal or prolonged bleeding after a dental procedure?**
- Yes
- No
Did you have any medical or bleeding problems, or blood loss, since birth?**
- Yes
- No
Does your family have any history of bleeding problems?**
- Yes
- No
Do you have any reason to believe that you have low blood pressure or low hemoglobin?**
- Yes
- No
Have you ever experienced fainting after an injection or medical procedure?**
- Yes
- No
Have you ever been bothered by a tight band on the underside of your penis that causes pain or bleeding during sex?**
- Yes
- No
If yes, please describe:
Please list any medications you are taking:
(name/dosage)
Contact Information
Please complete as many details as you can
Family Physician
First Last
Phone
Address
City Province
Referring Healthcare Professional
First Last
Phone
Address
City Province
Circumcision Consent
You must consent to the following:
*
- I have carefully considered the risks and benefits of this procedure and have discussed them with our family physician or other healthcare professional prior to seeing Dr. Christie.*
*
- I understand that Dr.Christie is one of the few doctors offering circumcision on adults under local anesthesia and they have explained to me this new approach.*
*
- I understand that complications after circumcision can occur, although the frequency varies with skill and experience of the doctor, and are infrequent in Dr. Christie's practice. Complications may include:*
  - Significant post-op bleeding (1/100)
  - Phimosis or narrowing of the shaft-skin opening over the head of the penis (1/500)
  - Infection requiring antibiotics (1/1000)
  - Sub-optimal cosmetic outcome (1/500)
  - Meatal stenosis or narrowing of the urethra (1/1000)
  - Trauma to the head of the penis (never in this practice)
  - Injury to the urethra including urethra-cutaneous fistula (1/1000)
  - More serious complications including death (never in this practice)
*
- I understand that it may be necessary for the doctor to use some or all of the following modalities to stop any bleeding should it occur:*
  - Pressure dressings
  - Skin glue
  - Bipolar cautery
  - Suturing
*
- I confirm that I understand that I must not take any anti-inflammatory medications in the 7 days before my procedure. Examples: ADVIL, IBUPROFEN, ASPIRIN, MOTRIN, etc.*
Name
This field is for validation purposes and should be left unchanged.

Adult Circumcision Registration

Patient Information

Medical History

Contact Information

Circumcision Consent

Gentle Procedures

Services

Appointments